Chest Tubes: Lesson Objectives 1. Identify 2 anatomical positions for CT placement and indication for each.

Why insert a chest tube?-(pg. 684) 2. Understand the equipment and preparation needed for insertion, maintenance, and removal; including understanding the different types of systems. (pg. 686-690) 3. Identify complications that may arise in a patient with a CT and apply a nursing intervention for each. -(pg. 689-690) 4. Be able to run through a simulation scenario using knowledge listed above and assessment skills pertinent to a CT.-(pg. 689) Required Reading: Elkin, Perry, & Potter, (2007). Nursing Interventions & Clinical Skills: 4th Edition. St. Louis, Missouri: Mosby, Inc. Lesson 1: Chest Tube Principles (pp. 684-690) Lesson 2: Chest Tube Drainage Systems (pp. 684-690) Lesson 3: Chest Tube Insertion & Maintenance Care (pp. 684-690) Lesson 4: Assisting With Removal of Chest Tubes (pp. 684-690) Recommended Recourses: Dev SP, Nascimento B Jr, Simone C, Chien V. N (2007) Chest Tube Insertion. Engl J Med 357(15). *(To access go to the CENE website from the School of Nursing website, click on Audiovisual recourses, then Videos in Clinical Medicine, and then the name of the video which is “Chest Tube Insertion.”

Simulation Scenario: Case description: Mr. Jones, a 65yo admitted with pleural effusion. O2 sats have been >90% on 3L/NC O2. A&Ox3, vital signs stable, no complaints and slept all night, wife spent the night. Chest tube system functioning appropriately. Smoking cessation teaching has not been started. PMH: Recent pneumonia, HTN, Anxiety, Smoker (1pack/day for 50 years). Family and Social History: Lives with wife and is normally independent with ADLs. Allergies: NKDA. Current Medications: 1. Albuterol and Atrovent HHN Q4h and Q1h prn 2. Captopril PO 25mg QD 3. Lasix 20mg PO QD 4. Potassium PO 20mEq QD 5. Ampicillin 1gm IV QD Patient information Name: Mr. Jones Age: 65 yo Gender: Male Weight: Height History of present illness: Recent pneumonia Past medical history: HTN, Anxiety Medications: Albuterol and Atrovent HHN Q4h and Q1h prn Captopril PO 25mg QD Lasix 20mg PO QD Potassium PO 20mEq QD Ampicillin 1gm IV QD

disease.A thin serous membrane. The lungs expand and relax because of the balance of pressure. Anatomy and Physiology of Respiration Chest Wall. or blood entering the intrapleural space causing the lung to collapse. Pleural space.The skin.Chest Tubes: Lesson Why insert a chest tube?. Thoracic cavity.The membrane that surrounds the lung Parietal pleura The membrane that surrounds the thoracic cavity. work in harmony to support the mechanics of breathing. Its rigid structure protects the lungs from injury.The inner aspect of the chest wall. Visceral pleura.The potential space between the visceral and parietal pleura. Breathing occurs because of a balance of respiratory gases monitored by chemoreceptors. This very thin layer of serous pleural fluid provides protection against friction as the lungs expand and contract and allows the parietal and visceral pleura to slide effortlessly over one another . The intercostals. The Pleura. along with the diaphragm. or surgery that results in air. containing the lungs. it is filled with approximately 4 mL of lubricating fluid. which folds over on itself and covers the entire chest cavity. ribs.To remove air and/or fluid from the pleural space in the case of trauma. fluid. and the intercostal muscles.

When the chest cavity stops expanding and the lungs are full of air. Small leaks may be absorbed spontaneously or may require interventions. At this time. returning the chest cavity to its resting stage. A pneumothorax can be open or closed. Chest tubes are commonly used after chest surgery and chest trauma and for pneumothorax or hemothorax to promote lung reexpansion.during each respiratory cycle. To expand the lungs. the principles of client management are the same. Expiration is a passive activity. During inspiration. During expiration. The usual intervention is the insertion of a chest tube to remove air and fluids from the pleural space. causing positive pressure. the respiratory muscles and diaphragm relax. the intercostal muscles pull outward and the diaphragm contracts and pulls downward. blood. pressure in the pleural space is negative (-4 to -10 mm Hg) with respect to the pressure of atmospheric air. which allows the air to leave the lungs. the intrapulmonic pressure is the same as the atmospheric pressure. This increase in negative pressure within the lungs causes air to rush into the lungs until the intrapulmonic pressure is equal to the pressure in the atmosphere. to prevent air or fluid from reentering the pleural space. disease.8 Air in the Pleural Space—Pneumothorax Pneumothorax: A pneumothorax is a collapse of lung tissue and is caused by a collection of air in the pleural space. 1. This gliding action prevents separation of the two layers of pleura. Normally. This decrease in space causes the intrapulmonic pressure to increase. whereas inspiration requires the muscles to push against negative pressure in the pleural cavity. A variety of chest tubes are on the market. depending on the mechanism of injury. Regardless of the system used. creating a positive pressure that collapses lung tissue. When the integrity of the pleural space is broken. This increase in size causes an increase in the amount of negative pressure (vacuum effect). . a passive relaxation of the respiratory muscles causes the chest cavity space to decrease. The loss of negative intrapleural pressure causes the lung to collapse. Reasons for Using a Chest Tube Trauma. the pleural space fills with air and/or fluid. and to reestablish normal intrapleural and intrapulmonic pressures. or surgery can result in air. The expanding lungs cause the intrapulmonic pressure to fall lower than atmospheric pressure. negative intrapleural pressure must be maintained. A chest tube is a catheter inserted through the thorax to remove fluid and/or air. or fluid leaking into the intrapleural space. and lung tissue collapses. thereby increasing the size of the chest cavity.

such as the vena cava.g. trachea and heart) shift to the opposite (unaffected) side of the chest." Open pneumothorax may be caused by: o o Surgical thoracotomy Penetrating chest trauma—for example.. This causes an increased pressure on the great vessels. which causes decreased venous return and subsequent reduced cardiac output. such as obstruction of the chest tube by a blood clot . The contents in the mediastinum (e. Tension pneumothorax can be caused by: • • • • Kinking or clamping of the chest tube Mechanical ventilation Cardiopulmonary resuscitation (CPR) Prolonged occlusion of chest tubes. It is a medical emergency.• Closed pneumothorax: Occurs without external injury and may be caused by: o The rupture of an emphysematous bleb (a large bulla resulting from the destruction caused by emphysema) on the visceral pleura of the lung (called a spontaneous pneumothorax) o o Perforation of the esophagus Nicking the visceral pleura and breaking the integrity of the pleural space during the insertion of a subclavian intravenous catheter or an abdominal paracentesis catheter o Secondary lung injuries such as a lung abscess or fractured ribs from the chest striking the steering wheel in an automobile accident • Open pneumothorax: Results from external injury through the chest wall and into the pleural space.9 Air in the Pleural Space—Tension Pneumothorax A tension pneumothorax is a type of pneumothorax in which air can enter the pleural space but cannot escape via the route of entry. The sound of air moving in and out of the wound as the client breathes results in this injury being referred to as a "sucking chest wound. a gunshot or knife wound 1.

the normal negative intrapleural pressure is reestablished. and is connected to a drainage system. Apical (second or third intercostal space) and anterior chest tube placement promotes removal of air. The chest tube facilitates the removal of air or drainage of fluid and blood from the pleural space. Frequently applying suction assists this drainage. lipid-based lymphatic fluid that enters the pleural space. Fluid in the intrapleural space is affected by gravity. .10 Fluid in the Pleural Space Hemothorax: This is the presence of blood.1. in the pleural space. A closed chest drainage system with or without suction is attached to the chest tube to promote drainage of air and fluid. preventing its accumulation around the heart. The chest tube is inserted through a small surgical incision into the pleural space. This tube drains blood or fluid.12 Chest Tube Location A chest tube is a catheter designed specifically for insertion between the parietal and visceral pleura. these chest tubes are placed high. as with a hemothorax. they may drain into separate drainage systems or they may be connected with a Y connector for drainage into a single unit. malignancy. Lung reexpansion occurs as the fluid or air is removed from the pleural space. A mediastinal tube is commonly used after open heart surgery. just below the sternum. causing a pleural effusion secondary to trauma. Because air rises. If two chest tubes are required because there is both air and fluid in the pleural cavity. Tubes placed in these positions drain blood and fluid. Chylothorax: Chyle is the white. and as a result. or as a consequence of thoracic surgery the effusion causes collapse of the lung. watery. Chest tubes are placed low (usually in the fifth or sixth intercostal space but can be in the seventh or eighth as well) and posterior or lateral to drain fluid. Fluid drainage is expected after open-chest surgery and with some chest trauma. The location of the chest tube indicates the type of drainage expected. A mediastinal chest tube is placed in the mediastinum. 1. which results in the partial or complete collapse of the lung. The air is discharged into the atmosphere and drainage is minimal in the collection chamber. which is necessary in the case of a pneumothorax. allowing evacuation of air from the intrapleural space and allowing the lung to reexpand.

positioning of patient. While obtaining informed consent is the responsibility of the physician. Removal of the chest tube is also the responsibility of the physician. 2. Physicians-insertion of chest tube catheters.18 Medical Staff Chest Tube Responsibilities for insertion. you should verify the presence of a signed informed consent document before the start of the procedure. Equipment setup.2 Introduction There are two types of commercial drainage systems: the water-seal and the waterless systems. Water-Seal Systems • Waterless Systems • One-bottle water-seal system Two-chamber water-seal system Three-chamber water-seal system Two-chamber waterless system Three-chamber waterless system • • • . Staff nurse. and monitoring.1. Chest tube insertions usually occur: • At the bedside. especially in an emergency and/or when attempting to correct a pleural effusion • • • In the postanesthesia recovery unit (PACU) In the operating room (OR) In interventional radiology (x-ray/radiology) special procedures rooms • In emergency or trauma care areas Remember that this procedure requires informed consent.assists during a chest tube insertion.

fluid or air is forced out of the intrapleural space. this fluid or air displaces the air present in the chamber by pushing it through the water seal and out of the system into the atmosphere.3 Water-Seal Systems Two-Chamber Water-Seal System On expiration. On entering the drainage collection chamber. The water-seal chamber must be left open for air to drain. 2. The chamber is filled to the set volume for the .g. When it is tipped or overturned. the chest tube system must remain upright. A prescribed amount of sterile fluid (e. The amount of sterile water added depends on the manufacturer's recommendations. air is unable to vent (leave) the system. Gravity pulls air or fluid through the chest tube into the drainage collection chamber. which is then attached to a suction source by tubing. the water seal is disrupted. If the tubing is clamped.Review the operating instructions for the specific unit(s) used within your organization before using them. the three-chamber water-seal system is set up with the suction control chamber added. Three-Chamber Water-Seal System If suction is to be used. To maintain the waterseal system. 20 cm of water) is poured into the suction control chamber..

Instead. accidentally tipping over the system is less of an issue than with a water system that can affect a client's health. gentle bubbling. causing the excess suction to dissipate. The absence of bubbling indicates that the suction level is inadequate to function. As the fluid level decreases. 2. Sterile water may need to be added several times a day because of evaporation.prescribed amount of suction. the amount of suction also declines. Most of the container serves as the drainage chamber. The extra air pulled into the chamber causes vigorous bubbling. which is set by a suction control dial after the suction source is turned on. The suction setting should be raised to restore gentle bubbling. The suction chamber operates without water. It does require the addition of 15 mL of fluid for visualization. The indicator's function is to identify one of the following: .4 Waterless Systems Two-Chamber Waterless System The waterless system's principles are similar to those of the water-seal system except that the system operates without fluid. air is pulled into the suction control chamber through an inlet. Since the system is dry. A diagnostic air-leak indicator is located on the face of the unit. This provides the prescribed amount of suction (negative pressure). If the suction source delivers more negative pressure than the suction control chamber water level allows. If this occurs. A one-way valve located near the top of the system replaces the water seal. The wall or portable suction device is turned up until the water in the suction control bottle exhibits a continuous. it contains a float ball. the suction source setting needs to be lowered to reduce noise and evaporation of the fluid.

it contains a float ball that is adjusted by a dial that controls the level of suction after a suction source is turned on. The chamber or float ball setting is a safety factor to reduce the possibility that the intrapleural tissues will receive too much suction. The indicator does require a small amount of fluid (e. Principles of this system include: • Since the system is dry. while facing the system. Three-Chamber Waterless System If suction is ordered. A one-way check valve located at the top of the system vents air escaping from the pleural space and prevents atmospheric air from entering the system. • It has a large fluid drainage capacity. the lung is .11 Waterless Drainage Systems The waterless system's principles are similar to those of the water-seal system. • An air leak is in the system if. this is indicated by a gentle tidaling of the fluid in the diagnostic indicator. There are usually two suction settings: one at either the suction control chamber or at the float ball setting and the other at the suction source. the source of the air leak must be located and corrected.g. and set the float ball at the prescribed setting. accidentally tipping over the system can occur without compromising the client's condition. If after 2 to 3 days tidaling stops. 2. • It allows you to check for an air leak through the diagnostic air-leak indicator that is located on the front of the unit. • Fluid is unnecessary to create a seal. • The lung is probably reexpanded if after 2 or 3 days the tidaling has stopped. The lung is reexpanding normally when a gentle tidaling is present in the diagnostic air-leak indicator. 15 mL of fluid). increase the suction source setting until it rises to the proper level.• The lung is expanding normally. The system is now functioning with suction. turn the suction on. This indicator is important for monitoring the function of the waterless system.. • It has a suction chamber that functions without water. If the float ball remains below the prescribed level. Instead. the observer sees the fluid bubbling left to right. Most of the unit is a drainage chamber. attach the suction chamber port to the suction source tubing. causing injury.

• Breath sounds are auscultated in all lobes. 2002). • The client reports no chest pain.  Tubing for kinks. a left-to-right bubbling indicates the presence of a leak. which should be upright and below level of tube insertion This facilitates drainage. 3.  Expected outcomes after completion of the procedure include: • • The client is oriented and more relaxed.16 Evaluation of Client: After insertion • For clients who have chest tubes: o Observe: Chest tube dressing and site surrounding tube insertion This ensures that the dressing is intact and an occlusive seal remains without air or fluid leaks and that the area surrounding the insertion site is free of drainage or skin irritation (Carroll. However. Vital signs are stable and move toward normal. Reexpansion of the lung promotes normal respirations.  Chest drainage system. or clotted drainage increases the client's risk for infection. . This indicates correct placement and patency of the chest tube drainage system. atelectasis. dependent loops. preventing fluid accumulation in chest cavity. Decreased hypoxia improves vital sign measures. The hypoxia is relieved.usually reexpanded. The presence of kinks. the system must be in this position to function properly. which must be identified and treated. or clots This maintains a patent. • The chest tube remains in place until the lung is fully expanded. Lung expansion is symmetrical. • Pulse Oximetry reading for SpO2 is stable or improved and respirations are nonlabored. dependent loops. and tension pneumothorax. Reexpansion of the lung reduces chest pain. and the chest drainage system remains airtight. freely draining system.

The speed of reexpansion depends on the client and the circumstances surrounding the collapse of the lung. Monitor the chest dressing carefully. Within normal limits (for Blood pressure them) decreased and heart rate increased. marked cyanosis.• Gentle tidaling (fluctuations or rocking) is evident in the water seal or diagnostic indicator. vital signs should be checked at least every 15 minutes. Remember that during the first 2 hours. such as excessive blood loss or tension pneumothorax. Observe your client's skin characteristics. Perform a focused pulmonary assessment. Notify the physician immediately. and/or mediastinal shift are critical and indicate a severe change in client status. indicating possible bleeding Within normal limits Decreasing. This indicates that the system is functioning normally. a decrease in breath sounds over the affected and nonaffected lungs. Evaluate the client for decreased respiratory distress and chest pain and evaluate breath sounds over the affected lung area. Normal Alert and oriented Abnormal Drowsy and/or confused Pale or cyanotic Cool and diaphoretic Shallow and rapid Observe your client's skin tone. asymmetrical chest movements. After insertion of the chest tube. It should be occlusive and intact at all times to prevent an air leak. An increase in respiratory distress and/or chest pain. hypotension. . Normal (for them) Warm and dry Observe your client's breathing Nonlabored and deep pattern. breath sounds should come back on the side of the pneumothorax/hemothorax as the lung tissue reexpands. the presence of subcutaneous emphysema around the tube insertion site or neck. paying special attention to bilateral lung sounds. Then every 4 hours thereafter. or below 90% Measure your client's PaO2. Ask the client to rate the level of comfort on a scale of 0 to 10. Note and monitor any drainage for color and amount. Assessment Activity Observe your client's level of consciousness. Set up a vital signs schedule based on the directions of the physician and the client's status. tachycardia. It reflects changes in intrapleural pressure. Measure your client's vital signs. Report any abnormalities such as excessive bleeding to the physician.

18 Evaluation of Chest Tube Functioning—Waterless System . The tubing to the suction source should be free of obstruction. • Water-seal system—bubbling in the suction control chamber (when suction is being used): The suction control chamber has a constant. below the client's chest above the client's chest • Subcutaneous emphysema—air that is being trapped in the subcutaneous tissue. trapped air is noted on palpation 3. Check the fluid level in the water-seal chamber frequently and replace it as needed. the bubbling stops. secure. 3. and/or looped Auscultate your client's lung for Bilaterally equal reexpansion. Observe the chest tube dressing. and Tipped. and drainage system. Fluid continues to fluctuate in the water seal on inspiration and expiration until the lung is reexpanded or the system becomes occluded. This procedure should be done without disrupting the chest tube and water seal. Dry and intact Taped and unkinked Observe the performance of the Upright. These are from air that was present in the system and in the client's intrapleural space. bubbles are expected from the chamber.17 Evaluation of Chest Tube Functioning—Water-Seal System Monitor the water seal for fluctuations with client's inspiration and expiration. Observe tubing connections. and the suction source should be turned to the appropriate setting. Pain free Observe your client's emotional Calm status. kinked. Follow the product manufacturer's recommendations on how to replace the sterile water or saline.Assessment Activity Normal Abnormal Unequal Requires analgesic medication Anxious and restless Bleeding through the dressing Untaped. gentle bubbling. • Water-seal system—bubbling in the water-seal chamber: When the system is initially connected to the client. Ask your client about pain level. After a short time. loose.

The float ball allows only the level of suction that is dictated by its setting. The chest drainage system should be upright and below the level of tube insertion. Have the client cough to maintain patency and promote lung expansion. tape the two padded hemostats to the foot of the client's bed or wherever recommended at your facility. • Waterless system—suction control (float ball): Diagnostic indicator indicates the amount of suction the client's intrapleural space is receiving. • Waterless system: Observe diagnostic indicator for fluctuations with client's inspirations and expirations. to empty or change the collection system. the suction float ball cannot reach the prescribed setting. periodic lifting and draining of the tube will also promote pleural drainage. This indicates that the system is functioning properly. Furthermore. observe the tubing and drainage for clots or material that could occlude flow. Regardless of the type of system the client has. fluid should rise in the water seal or diagnostic indicator with inspiration and fall with expiration (referred to as tidaling). In the non–mechanically ventilated client. However. If the suction source is set too low.20 Unexpected Outcomes Unexpected Outcomes Air leak unrelated to Interventions • Locate source. 3. The system must be in this position to function and to facilitate proper drainage. the suction must be increased for the float ball to reach the prescribed setting. These may be used to double clamp the chest tube to assess for an air leak. .Monitor diagnostic indicator for fluctuations with client's inspiration and expiration. when a dependent loop is unavoidable. The opposite occurs in the client who is mechanically ventilated. In this case. The suction float ball dictates the amount of suction in the system. Straight and coiled drainage tube positions are optimal for pleural drainage. and to assess if client is ready to have the chest tube removed (MD order required).

Unexpected Outcomes No chest tube drainage Interventions • Observe for kink in chest drainage system. Observe for possible clot in chest drainage system. Notify physician. Observe for mediastinal shift or respiratory distress (medical emergency). Notify physician. • . Have assistant apply gauze dressing and tape securely. Monitor drainage.Unexpected Outcomes client's respirations Interventions • Notify physician. Interventions • Immediately apply pressure over chest tube insertion site. Assess client's cardiopulmonary status. • • Unexpected Outcomes Substantial increase in bright red drainage Interventions • • • Obtain vital signs. • • • Unexpected Outcomes Chest tube is dislodged. Notify physician.

However. Check agency policy and if instructed. cross-clamp chest tube closest to client's chest. • Chest tubes are never routinely clamped when the client is ambulating and/or during transportation to another location. If you see bubbling in the water-seal chamber during inspiration and expiration. Assess for location of leak by clamping chest tube with two rubber-shod or toothless clamps close to the chest wall. evaluate the possible causes. Following agency policy. If the bubbling stops. unclamp the tube immediately and notify the physician. If the client experiences shortness of breath. bubbling is common during expiration as the air is evacuated from the pleural space. Notify physician. the air . Unclamp chest tube. The goal in this case is to determine a client's readiness for removal of the chest tube catheter. • Chest tubes may be clamped when testing for an air leak in the system. Reinforce dressing. • • • 3. Once a tube is inserted. Clamping the Chest Tube: • Chest tube clamping is done only in preparation for removal of the chest tube after the lung tissue has reexpanded. Interventions • • Tighten loose connections. if bubbling stops. An air leak can occur immediately or hours after the lung has reexpanded. • Realize that a leak can occur from within the chest or at any point along the tubing and even within the drainage system itself. air leak is inside client's thorax or at chest tube insertion site. you will need to clamp the tube briefly to determine the location of the leak. chest pain. or any other adverse effect.23 Chest Tube Controversy Two practices in the care of chest tubes are currently controversial. clamping briefly may be necessary to empty or change a collection system. Bubbling during inspiration indicates a leak somewhere within the system. indicating leak between client and water seal.Unexpected Outcomes Continuous bubbling is seen in waterseal chamber.

You should then quickly cleanse the ends of the tubing and reconnect it to the drainage system. Furthermore. The concern is that stripping or vigorous milking of a chest tube increases the positive pressure inside the drainage system. If bubbling continues with the clamps near the chest wall. Stripping is compressing with your hands the length of the tubing beginning at the client and continuing until the drainage unit is reached. . which may draw lung tissue into the eyelets of the chest tube and cause significant tissue damage. An airtight system is required for the chest tube to function properly. this skill is outside the scope of AP. Milking and/or Stripping the Tubing: • Milking or stripping chest tubes should be done only when there is a physician's order and an organizational policy covering this practice. Consider changing to a new drainage system after the tubing is secured. Have your client exhale fully and cough hard so that any excess amount of air is released from the intrapleural space. Release the clamp at once and place an immediate call to the physician. microorganisms could have the opportunity to enter the closed system and could ascend to the client. gradually move one clamp at a time down the drainage tubing away from the client and toward the suction control chamber. and you want to ensure that the drainage system is undamaged. Replace the tubing or secure the connection and release clamps. If bubbling still continues. This procedure is designed to promote the flow of fluid through the tube when clots or other debris have caused considerable slowing or occlusion and should be done only with tubes that are draining blood. • Mediastinal tubes may be milked after open heart surgery to ensure that blood clots never occlude the tube and stop drainage.leak is inside the chest wall. this indicates that the leak is in the drainage system. • If the tubing becomes disconnected from the drainage system. problem solving. Milking is compressing and releasing the tube sequentially with your hands. with disconnection.3 Delegation o Since chest tube care and maintenance are highly complex skills requiring critical thinking. It is important that you follow agency guidelines under these circumstances 3. and interventions. When bubbling stops. the leak is in section of tubing or connection between the clamps. clamping the tube is unnecessary. Change the drainage system and release the clamps.

3. hypotension. it is important for you to obtain a baseline assessment within 30 minutes before chest tube insertion and to perform ongoing assessment once the chest tube is established. Baseline vital signs are essential for any invasive procedure. heparin. and tape are common allergens. Chlorhexidine is an antiseptic used to cleanse the skin. Leave the blood pressure cuff loosely on the client's arm opposite the side of the chest requiring the chest tube so it will be available for use during the procedure. The chest tube will be held in place with tape. If latex is an issue. lidocaine. The degree of the signs and symptoms associated with respiratory distress are related to the size of the pneumothorax or hemothorax or preexisting illness of the client. Mediastinal shift (shifting of the trachea and heart to the unaffected side) also indicates a tension pneumothorax. or platelet aggregation inhibitors such as ticlopidine can increase procedurerelated blood loss. Anticoagulation therapy such as aspirin. • Obtain baseline and serial vital signs. oxygen saturation (SpO2 via pulse oximetry) and level of orientation. and vital signs are taken serially. make sure that the equipment assembled earlier is latex free.4 Assessment: Preinsertion Because a chest tube insertion may affect both pulmonary and cardiac function. • Assess pulmonary status including: o o Decreased breath sounds over affected lung area Additional signs and symptoms of increased respiratory distress: marked cyanosis. . Ask if the client has had a problem with medications. Clients requiring chest tube insertion frequently have respiratory distress. or anything applied to the skin. asymmetrical chest movements o Chest pain on inspiration. warfarin. latex. • Assess the client for known allergies. • Review the client's medication record for anticoagulant therapy. Iodine. Lidocaine is a local anesthetic administered to reduce pain. 2002) Clients in need of chest tubes have impaired oxygenation and ventilation. Changes in level of orientation may indicate decreased levels of oxygen and/or hypoxia. Sharp stabbing chest pain with or without decreased blood pressure and increased heart rate may indicate a worsening of the collapse of lung tissue or a tension pneumothorax. and tachycardia (Carroll.

• If possible. The presence of a pneumothorax or hemothorax is painful. there is discomfort associated with the presence of a chest tube. • Verify that a signed consent exists for this procedure.6 Planning—Equipment Inserting a chest tube requires the following items: • Oxygen tubing or mask and flow meter if the client requires oxygen during the procedure . or clotted drainage increases the client's risk for infection. preventing fluid accumulation in chest cavity.• Review the client's recent lab results. The presence of kinks. the client may have low values requiring either a blood transfusion or re-infusion of chest tube drainage. As a result of this discomfort. ask the client to rate the level of comfort on a scale of 0 to 10. frequently causing a sharp inspiratory pain.  Chest drainage system.  3. 2002). dependent loops. and tension pneumothorax. atelectasis. which should be upright and below level of tube insertion This facilitates drainage. dependent loops. it is the physician's responsibility to obtain prior to beginning the procedure. Serial hematocrit and hemoglobin values may indicate whether there is continued active bleeding. If the client experienced a hemothorax or pneumohemothorax.  Tubing for kinks. the system must be in this position to function properly. clients tend to avoid coughing or changing position in an effort to minimize this pain. or clots This maintains a patent. Pay close attention to hemoglobin and hematocrit values. • For clients who have chest tubes: o Observe: Chest tube dressing and site surrounding tube insertion This ensures that the dressing is intact and an occlusive seal remains without air or fluid leaks and that the area surrounding the insertion site is free of drainage or skin irritation (Carroll. freely draining system. Recall. In addition.

) • Sterile water or sterile normal saline as recommended by the manufacturer and/or agency policy • Portable suction setup if a wall suction unit is unavailable and suction will be required (Extra tubing for the suction unit should be available.) • A chest tube (The size is determined by the physician performing the insertion.) • Local anesthetic with appropriate-size syringes and needles (This may be unnecessary if the insertion is emergent. o Reusable trays are cleaned and sterilized after use.) • Sterile chest tube tray (These trays can either be reusable or disposable. Verify that each reusable tray includes:          Sterile drapes Local anesthetic A knife handle and blades of varying size Suture material of varying size and material Chest tube clamp Two 8-inch curved Kelly clamps (hemostats) Multiple 4-by-4 and 2-by-2 gauze sponges Suture scissors Suture holder . Disposable trays are discarded after client use.) o Disposable trays contain most of the equipment that you will need except for anesthetic.• • Pulse oximetry unit A chest tube drainage system (Read the information on the wrapper of the drainage system to determine if additional equipment is required by the unit that you will be using.

• The chest tube remains in place until the lung is fully expanded. • Breath sounds are auscultated in all lobes. Reexpansion of the lung promotes normal respirations.. and 3.] • Two large hemostats (Kelly clamps) with the teeth protected by plastic or rubber tubing (rubber-shod) for each chest tube inserted • Sterile attire (In some facilities. always verify agency policy. This indicates correct placement and patency of the chest tube drainage system. . sterile attire may be required for the nurse directly assisting in the procedure as well as the person inserting the chest tube. a large dressing (e. 4-by-4s. Become familiar with the content of the trays so your response time during critical events is enhanced. • Pulse Oximetry reading for SpO2 is stable or improved and respirations are nonlabored. Decreased hypoxia improves vital sign measures. The hypoxia is relieved. Reexpansion of the lung reduces chest pain.) • Clean gloves for use after the procedure when disposing of used equipment and sponges • • 1-inch tape for taping all of the tubing connections Alcohol wipes Note: It is important that you become familiar with your agency's policies with respect to the use of disposable or reusable chest tube trays.or 4-inch tape or elastic bandage (Elastoplast).• Dressing materials for covering the exit site following chest tube insertion [The dressing materials include petrolatum gauze. 3. ABD or combine pad).g. Lung expansion is symmetrical. Vital signs are stable and move toward normal.8 Planning—Expected Outcomes Expected outcomes after completion of the procedure include: • • The client is oriented and more relaxed. and the chest drainage system remains airtight. • The client reports no chest pain.

You prepare the client for chest tube removal by: • Assessing the need for preremoval analgesia and obtaining the required medication orders • Instructing the client about the process and what will be requested of the client During removal of the chest tube.3 Delegation Assisting with the removal of a chest tube is outside the scope of responsibility of AP.• Gentle tidaling (fluctuations or rocking) is evident in the water seal or diagnostic indicator. you should apply standard principles for infection control whenever providing nursing care to a client.2 Introduction A halt in bubbling for 24 hours and a decrease in drainage to less than 50 mL per day are good indicators that the client's lung has reexpanded. 4. Your role is to provide assistance to the physician and support your client. 4. 3. Auscultation should reveal breath sounds over the reexpanded lung. AP may. It reflects changes in intrapleural pressure. This maneuver prevents air from being sucked into the chest as the tube is pulled out and before an occlusive dressing is applied. 4. you will be able to: • Describe the process of chest tube removal.10 Pre-Procedure Preparation As a health care provider. Practicing these principles will protect both you and your client from disease and injury. Removal of a chest tube once lung reexpansion has occurred is the responsibility of the physician. assist you with: . it is important that the client takes a deep breath and holds it until the physician has removed the tube.1 Lesson Objectives: Chest Tube removal Upon completion of this lesson. This indicates that the system is functioning normally. however.

The purpose of the film is to visualize the degree of lung expansion and is often the determinant for removal of the chest tube. without bubbling or tidaling. Drainage should decrease to less than 50 mL per day for lung reexpansion. . • Your pulmonary assessment and those of the other nurses from the previous 24-hour period. • Once the client's VS and SpO2 are considered stable. It is best if you can provide the trend of this information for the previous 24-hour period. It is possible that the physician will have spoken with the radiologist about the findings. or increased anxiety. Pay special attention to: o o Any renewed complaints of chest pain. Certain assessment parameters must be met prior to removal of a chest tube. the lung is probably fully reexpanded. Inform the physician about: • The degree of bubbling noted in the water-seal chamber. increased chest pain. • Often a chest x-ray is ordered several hours before the client is due to have the tube removed. specify the frequency of measurement and the specific parameters the AP should monitor and report. dizziness. A halt in fluctuation for 24 hours indicates that the lung is expanded. but you should have the report or the films available in case there are any questions or concerns. The equality of chest expansion. Obtain the x-ray report and have it available when the physician arrives. If the water seal is quiet. 4. and it is your responsibility to provide this information to the physician so that an informed decision can be made. • Report any dislodgement of the dressing or drainage on the dressing.5 Assessment The chest tube should remain until the lung is totally reexpanded. • The amount of fluid that has drained within the previous 24-hour period.• • Gathering equipment as needed and bringing it to the bedside Positioning the client for the procedure You should instruct the AP who care for the client after chest tube removal to: • Immediately report client sensations of shortness of breath.

• Determine if the client understands the chest tube removal procedure. It is important to note the last dose of the medication. Normal percussion occurs with reexpansion. The presence of a chest tube is painful. unclamp the tube.7 Planning—Equipment Removing a chest tube requires the following items: • • • A suture set Sterile scissors Sterile forceps . Chest tube removal is painful. You should determine what the client needs to know about the procedure and assist in reducing anxiety. Before chest tube removal: • Assess client's level of comfort by using a 0-to-10 scale and determine when the last analgesic medication was given. and the client frequently requires analgesic medication. and additional analgesia may be necessary. • If the physician ordered that the chest tube be clamped before removal. monitor vital signs. provide the following assessment: o o o o o Client tolerance Alterations in respiratory effort Alterations in vital signs Complaints of chest pain Any increases in anxiety Note: If you are at all concerned with the client's tolerance or if there are any indications that the client's respiratory or cardiac status is compromised. o Your findings on auscultation. Absence of lung sounds indicates a deflated lung.o Your finding on percussion. and contact the physician immediately. The presence of hyperresonance in the lungs indicates a possible tension pneumothorax. 4.

9 Planning—Expected Outcomes You should be able to predict positive and negative outcomes from removal of the chest tube. As a result. leave this intact unless it is needed • A replacement chest tube drainage system (in case the client's lung collapses during the procedure). The lung remains expanded after chest tube removal. This is why you have an unassembled . Positive Outcomes: • • • The client tolerates the procedure without undue discomfort. this is an emergent situation. leave this in its wrapper unless it is needed 4. Although rare. Negative Outcomes: • The lung collapses during removal of the tube.• Suture material to the specification of the physician and/or advanced practice registered nurse • • • • Sterile gloves Clean gloves Face mask with shield Sterile dressing materials: o o o Petrolatum gauze dressing (required) 4-by-4 gauze sponges A large gauze dressing (such as an ABD pad or combine dressing) o 3. you should be able to implement the correct intervention if a negative outcome occurs so that your client remains safe. The chest wound at the point of insertion heals without infection or other complications.or 4-inch tape or a self-stick elastic bandage (Elastoplast) cut into strips • A sterile chest tube tray (in case the client's lung collapses during the procedure).

Be prepared to provide more pain medication as needed. This identifies the early signs of incomplete lung expansion. This detects the early signs and symptoms of complications. Chest tubes may need reinsertion. When changing the dressing. • Ask about the client's level of pain or comfort. This determines the client's tolerance of the procedure. You should continue to assess your client's respiratory and pain status. clients will take shallow breaths. Assess for respiratory distress immediately after tube removal and during the first few hours after removal. Notify the physician. oxygen saturation. • The client complains of discomfort. Encourage your client to deep breathe and cough to maintain a clear airway and promote lung expansion. and psychological status. • Check the chest dressing for drainage and patency. There could be signs that the wound is poorly closed. observe the wound for signs of healing.13 Evaluation • The period after chest tube removal should be a time of healing for the client. 4. This ensures occlusion and proper healing of the chest wound. 4. • There is an alteration in vitals signs immediately after removal of the tube. • Evaluate vital signs. It is painful. Subcutaneous emphysema results from the entrance of air into the subcutaneous space. pulmonary status. This provides for early notification of the physician if adverse symptoms occur. • Review the chest x-ray film.replacement chest tube drainage system and unopened sterile chest tube tray available. and as a result. Observe for nonverbal cues of pain and evaluate level of discomfort on a scale of 0 to 10. Palpate along the site where the tube was inserted and observe the client for subcutaneous emphysema. • Evaluate lung sounds.14 Documentation The following information should be included in the medical record of a client after chest tube removal: .

• • . obtain vital signs and SpO2.15 Unexpected Outcomes Unexpected Outcomes Dyspnea.• • • • Vital signs and SpO2 before and after the procedure Client's emotional level before. during. Prepare for possible chest tube reinsertion. and after the procedure Client's overall tolerance of the procedure Client's level of comfort Sample documentation of findings: 4. and remain with client. Notify physician. labored respirations Related Interventions • This indicates a potential recurrence of pneumothorax or hemothorax.

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